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A postsurgical client has been receiving morphine by patient-controlled analgesia for 2 days. What action by the nurse best addresses potential adverse effects?

A.

administering a stool softener as prescribed

B.

auscultating the client's lung for adventitious sounds

C.

encouraging active range of motion exercises

D.

applying calf compressors as prescribed

Answer and Explanation

The Correct Answer is A

A. Administering a stool softener is essential as opioids like morphine commonly cause constipation, and this proactive measure helps mitigate that adverse effect.  

 

B. While auscultating the lungs is important to monitor respiratory function, it does not specifically address a common adverse effect of morphine.  

 

C. Encouraging active range of motion exercises can help prevent complications from immobility but does not directly address the most common adverse effect of morphine.  

 

D. Applying calf compressors can help prevent deep vein thrombosis, but it is not the most effective action for addressing the specific adverse effects of morphine use.


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Correct Answer is B

Explanation

A. Prothrombin time (PT) is used to monitor warfarin therapy, not heparin therapy.

B. Activated partial thromboplastin time (aPTT) is the primary laboratory test used to assess the effectiveness of heparin therapy, measuring the time it takes for blood to clot and ensuring therapeutic levels.

C. The International normalized ratio (INR) is also related to warfarin therapy rather than heparin.

D. Serum potassium level is not relevant for assessing heparin therapy but may be monitored for other reasons.

Correct Answer is A

Explanation

A. Try not to swallow while the pill dissolves is correct because sublingual medications are designed to be absorbed directly into the bloodstream through the mucous membranes under the tongue, and swallowing may hinder this absorption.

B. Take a big drink of water and swallow the pill is incorrect because sublingual medications should not be swallowed with water as they need to dissolve under the tongue.

C. Swallow frequently to get the best benefit is incorrect, as this can interfere with the absorption of the medication.

D. Chew the pill so it will dissolve faster is incorrect since chewing may destroy the sublingual formulation, preventing it from working as intended.

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